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Style Standards to Improve Data Quality
and Interoperability
Session 195, February 14, 2019
Laura Bryan, MS, MT(ASCP), CHDS, AHDI-F, Chair, Book of Style Development Team, AHDI
Susan Dooley, MHA, CMT, AHDI-F, National Leadership Board, AHDI
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Laura Bryan, MS, MT(ASCP), CHDS, AHDI-F
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Susan Dooley, MHA, CMT, AHDI-F
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Style standards and best practices that support clinical care, data
exchange, aggregation, integration, and normalization
Objectives
Introduction
Definition, purpose, and elements of style
Relevant SDOs
Value and benefits
Examples
Challenges
Recommendations
Q&A
Agenda
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Explain the benefits of applying style and format to information
exchange, data aggregation, natural language processing and
artificial intelligence
Describe the purpose of style standards related to clinical and
technical information and identify standards developing
organizations that promulgate those standards
Recognize the value of style standards to improve communication
among clinicians and to enhance patient safety
Recognize the value of a single-source reference tool for writing
clinical and technical information
Compare and contrast formatted vs non-formatted clinical data
Learning Objectives
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Who we are and what we do
Association for Healthcare Documentation Integrity (HIMSS
Endorser)
Professional association for documentation specialists
Develop, promulgate, and apply standards for communicating
clinical and technical information
First style manual published in early 80s
Advocate for highest quality healthcare documentation
Promote standards that enhance current and future outcomes
of EHR use
Introduction
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Establishes style to improve communication
Promotes consistency within and across multiple documents
Outlines best practice in usage and language composition,
visual composition, orthography and typography
Promotes best practice in ethics (such as authorship, research
ethics, and disclosure) and compliance (technical and
regulatory)
Purpose of Style Guides
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Improve written communication
Reduce ambiguity
Eliminate confusion
Promote uniformity within and across
documents
Purpose of Style Guides
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Abbreviations, acronyms, initialisms
Symbolization (eg, genes, protein products of genes)
Character spacing (eg, medication regimens, chemical
terms, alphanumeric terms)
Dates and times
Use of punctuation marks in scientific nomenclature
Colon, semicolon
Diacritics, asterisks, ampersand, hash mark
Elements of Style
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Units of measure
Pharmaceutical regimens
Cancer protocols
Laboratory results
Chemical elements
Genetics
Disease classifications
Abbreviations, medical slang and lingo
Relevant Style Standards
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Building and formatting templates
Copy and paste policies
Documentation best practices
Normals and standard text
Gender pronouns
Facility Best Practices
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Decreases normalization effort
Provides guidance for those without expertise in
medical science
Informaticists
Engineers and programmers
Implementers
Improves
Data aggregation
Analysis
Exchange
Value to IT Industry
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“We and others in the industry that process the output
of EMR and documentation systems spend
considerable effort improving style and format within
documents. In many cases, the documentation
templates or formats have been designed for easier
entry but not for readability or interoperability."
Mark Morsch
VP of Technology, NLP Innovation
Optum360
Value to IT Industry
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Clear and unambiguous written
communication
Patient safety
Improved usability and readability
Promotes consistency and accuracy
Value to Clinicians and Patients
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Improves information exchange, data
integration, and data aggregation
Reduces data normalization tasks
Improves results from NLP and emerging
technologies such as AI
Reduces ambiguity or misinterpretation
Technical Benefits
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Compilation of relevant styles by numerous
SDOs
AMA
WHO
AJCC (classification and staging of
cancer)
ISMP ("Do Not Use" abbreviations)
A Single Source Reference
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Reduces research
No need to recreate the wheel at each
facility
Eliminates "guessing" or "googling"
Easy-to-use guide for those unfamiliar
with biological and chemical
terminologies
Value of a Single-Source Reference
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When to spell out or write numbers
How to write units of measure
How to write prescriptions
How to abbreviate clinical terms
How to write chemical formulas, lab
results, needle sizes
Questions Resolved by Style Guide
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P:
Fluids per primary care, lactic acid 0.9, antibiotics on board, blood
culture pending, procalcitonin 14.78, repeat.
Surgical workup with occasional WBC, 2+ GPCs, GNRs, GPRs, and
rare yeast, awaiting final culture.
Continue Diflucan and Zosyn.
Blood culture preliminary negative x2 days, sputum pending.
MRSA screen.
CBC and BMP in the morning.
Thank you for this consultation.
Example
Nonstandard abbreviations
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“History of gastric ulcer 2ry to NSAIDs.”
2ry
2/2
Creatinine 1.04, initial troponin negative, BNP 1K
qDay (daily)
d/t (due to)
Wx (workup)
Example
Nonstandard abbreviations
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Medication regimens
Full-dose aspirin and Crestor 10 mg at night. She has not been able
to get anything orally, for which she has been receiving the aspirin
300 mg p.r.
Example
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https://github.com/jddamore/ccda-samples/blob/master/z-infographic/medications.jpg
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Tylenol 500 mg 1 tablet orally daily as needed for 10 days
ceftriaxone 100 g injection twice a day for 8 days
darbepoetin alfa 0.5 mg/mL inject 1 mL once a week
Example
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Tylenol 500 mg 1 tablet orally daily as needed for 10 days
ceftriaxone 100 g injection twice a day for 8 days
darbepoetin alfa 0.5 mg/mL inject 1 mL once a week
Example
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“Dangerous” use of trailing decimal (ISMP)
Example
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Example
Nonstandard use of decimals
Inconsistent use of units of measure (cm, g, Celsius vs feet, lb, and Fahrenheit)
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Special characters that do not translate through data interfaces
Clinician dictated:
D: Per her last quantitative EEG, her peak alpha frequency was
9 Hz and at 15.58 UVSQ.”
mV
2
(microvolts squared)
Greek letter “mu” interpreted as “u,”
T: Per her last quantitative EEG, her peak alpha frequency was
9 Hz and at 15.58 mcV sq.
Example
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Variations in testing results
The FEV1-to-FVC ratio was 60%. It was 65% bronchodilators.
The FEV1-to-FVC ratio was 60%. Post-bronchodilation, there was
minimal improvement to 65%.
The FEV1-to-FVC ratio was 60%. There was no significant
improvement with bronchodilators.
Per standard:
FEV1/FVC 60%, post-bronchodilation 65%
Example
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Positive results indicated using bold, which could be lost in an
interface
Example
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Poor template construction with incorrect verbs confuses
intended meaning
Example
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Industry awareness
Industry education on the value and benefits
Consistent implementation across platforms
Educating users on correct style
Coordinating easy data entry with readability and
interoperability
Challenges
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Adopt documentation standards
Use a single-source reference
Employ certified documentation specialists
Recommendations
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Thank you for your attention!
Q&A
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Laura Bryan, MS, CHDS
Laura@mtwerks.com
Susan Dooley, MHA, CMT
susanddooley@gmail.com
www.AHDIonline.org
AHDI@AHDIonline.org
800-982-2182
Contact Information
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Book of Style and Standards for Clinical Documentation 4
th
Edition
(BOSS4CD)
by the Association for Healthcare Documentation Integrity
www.AHDIonline.org
Publishing Late Spring/Summer of 2019
Additional Information
Health Story Project Roundtable
March 4, 2019